Vertig : Causes and treatment

Vertigo is not a disease but a symptom of balance disorder which can be due to any number of causes. It is defined as an “illusion” or “hallucination” of movement. It is the feeling that you or your environment is moving or spinning when there is no actual movement.

Dizziness and imbalance are common causes of visit to primary health care physician and includes a broad range of sensations from severe vertigo to momentary lightheadedness. Vertigo is most common cause of referral to otolaryngology clinic.

Vertigo should not be confused with other terms related to imbalance like lightheadedness, unsteadiness, or drop attacks.

Vertigo is not fear of heights

Even today vertigo is confused as fear of heights (Acrophobia—meaning Dizzy feeling often experienced when looking down from a high place), which is not true vertigo.

“Alfred Hitchcock’s” movie “Vertigo” (1958) shows its lead character a San Francisco detective (James Stewart) has Acrophobia but people confused it with vertigo because of the name of the movie.

Mild Vertigo is very common, and the symptoms are not usually serious. Most patients who experience vertigo have disorder of the vestibular system.

Normal Balance requires

Resulting in movement of head and neck, legs, eyes and rest of the body to maintain the balance and have clear vision while person is moving.

Vertigo is caused by

conflict of information between inner ear and other sensory system or defect in central integration of vesitbular information in brain.

I. Causes of vertigo

Vertigo may be because of otologic, neurologic, or systemic reasons. Cause can often be diagnosed by patient’s description of the problem and thorough physical examination; other tests are sometimes needed

Causes of Otologic Vertigo

Benign paroxysmal positional vertigo

Meniere’s disease

Vestibular neuritis and related conditions

Bilateral vestibular loss (about 1%)

SCD and Fistula (rare)

Chronic otitis media

Eustachian tube dysfunction (the tube that links the inner ear with the space behind the nose)

Central (Neurologic) Causes of Vertigo

Multiple sclerosis

Tumor (Acoustic neuroma)

Vascular causes

Transient Ischemic Attacks or stroke

Vasculitis: SLE, PAN, Temporal arteritis

Systemic causes of Vertigo

Anaemia (Low Hemoglobin)

Hypogycemia

(Low Blood sugar)

Hypotension (Low Blood Pressure)

Drugs- Medicines such as salicylates, quinine and aminoglycosides

Viral Infection

II. Benign paroxysmal positional vertigo

Benign Paroxysmal Positional Vertigo (BPPV) is the most common form of vertigo and is characterized by the sensation of motion provoked by sudden head movements or moving the head in a certain direction. BPPV is caused by detachment of otoconia to semicircular canal from utricle and is usually not due to any serious disorder.

Short, intense, recurrent attacks of rotatory vertigo (usually lasting 10-20 seconds) are often the result of benign paroxysmal positional vertigo (BPPV). There is no tinnitus, hearing impairment, neurologic signs, and the gait is normal.

The nystagmus is not spontaneous, it is fatigable, & is directed towards the lowermost ear.

Meniere’s disease is because of dilatation of endolymphatic space of membranous labyrinth) and characterized by triad of symptoms– episodes of vertigo, Ringing in the Ear (Tinnitus), and fluctuating hearing loss.

Sudden attacks of severe vertigo may last for several hours accompanied by nausea and vomiting with symptoms free intervals. Patient may feel pressure in the ear before attack and hearing loss and discomfort to loud noise (Hyperacusis).

Etiology:

Over production of the endolymph

Vasospastic theory: Autonomic imbalance in the arterioles of the stria vascularis.

Herniation/rupture of the membranous labyrinth

Metabolic disturbances, either local or systemic

Allergy

This is to be differentiated from Meniere’s syndrome, wherein a known cause exists, & Meniere’s-like syndrome, wherein there is no fluctuation of hearing or episodic vertigo.

Lermoyez’ syndrome is another variant, characterized by progressively increasing hearing loss & vertigo, followed by vomiting, & then complete recovery.

Vestibular neuritis and labyrinthitis are sometimes used interchangeably but are two separate conditions, in labyrinthitis hearing loss is an additional feature.

Patients benefit from bed rest and symptom relief treatments. In patients with suppurative labyrinthitis, hospitalization with intravenous antibiotic treatment is required. Early mobilization and Vestibular rehabilitation exercises are beneficial for compensation of vestibular function.

Labyrinthitis

Vertigo may also be caused by inflammation within the Vestibular labyrinth –(ie complex fluid filled channels in the inner ear).

Viral infections such as a common cold or flu can spread to the labyrinth. Less commonly, labyrinthitis is caused by a bacterial infection of the inner ear (otitis media).

Labyrinthitis is characterized by sudden onset of vertigo and, and may be accompanied by hearing loss, ear pain and fever.

Vestibular neuritis

A viral infection can sometimes lead to infection to vestibular nerve or vestibular neuritis.

Characterized by sudden onset rotatory vertigo with nausea and vomiting. Patients are unsteady but can usually stand and walk. There is no loss of hearing.

Sudden Vestibular Failure (Vestibular neuronitis) is damage to the sensory neurons of the vestibular ganglion). One side labyrinth suddenly stops working.

Characterized by sudden vertigo with nausea and vomiting without auditory symptoms. Vertigo is continues which gradually improves.

Causes may be-

Head injury

Viral infection

Blockage of blood supply on end arteries

Multiple sclerosis

Diabetic neuropathy

Encephalitis

Corticosteroids and early rehabilitation may be beneficial for long-term outcomes.An antiviral medication is not found to be helpful.

V. Superior canal dehiscence syndrome (SSC

Presence of dehiscence (break in the continuity) in the bone covering superior canal is characterized by vertigo induced by loud noise, may be associated with conductive hearing loss, sensation of increased loudness of patient’s own voice (autophony) and pulsatile tinnitus .

Leakage of inner ear fluid into the middle ear can occur after a head injury, drastic changes in atmospheric pressure (such as when scuba diving), physical exertion, ear surgery, or chronic ear infections.

Patient with perilymph fistula has dizziness, nausea and unsteadiness while walking or standing which increases with activity and decreases with rest. Sometimes it is present at birth along with congenital hearing loss.

Central Dizziness

Migraine- associated vertigo (Vestibular Migraine) is a common but under diagnosed cause of episodic vertigo. The vertigo is usually followed by a headache. Some patients have prior history of similar episodes with periods free of headaches.

There is no definitive diagnostic test for migraine and sometimes typical headache is absent; the diagnosis can only be verified by the response to the migraine treatment

Stroke or TIA -The most feared diagnosis of true vertigo is a transient ischemic attack or stroke. It should always be excluded especially in patients with cardiovascular risk factors and central neurological findings.

Disruption of the blood flow to the inner ear can cause damage to balance and hearing system.

Vertigo is often the presenting symptom in Multiple sclerosis. The onset is usually abrupt, and examination of the eyes may reveal the inability of the eyes to move past the midline toward the nose.

Careful history Physical examination combined with MRI and spinal-fluid analysis helps in reaching to the diagnosis

Psychogenic vertigo

Anxiety disorder, hyperventilation and depression can manifest as chronic vertigo. Reassurance and counseling, cognitive behavioral therapy and medication are useful.

Trauma induced Vertigo

Head trauma -By direct injury to the labyrinth or by canalith dislodgement

Barotrauma- sudden atmospheric pressure changes (such as in pilots or divers) may cause perilymphatic fistula. Fistula usually heals in 2 weeks time with appropriate with bed rest and avoidance of straining and coughing. Surgical repair is required if there is progressive hearing loss.

Most disorders of the balance system are self-limiting and can be satisfactorily managed if the clinical tests and investigations point to a specific disorder but when the clinical tests and investigations point to vestibular disturbance of unknown etiology management becomes challenging task due to large number of potential underlying conditions. In theses cases Treatment for vertigo is mainly symptomatic with Reassurance to the patient, Physical therapy ,medicines. and sometimes surgery.